2. Overview
Case Report
• General Information
• Social History
• Medical History
• Nutritional History
• Medical Course of the Patient
Case Discussion
Implications of Findings to the Practice of Dietetics
References
Questions
3.
The Patient: “MS”, 66 year old obese Caucasian female
Admitted with abdominal pain, nausea, vomiting and acute
diverticulitis with suspected colorectal bladder fistula
She was diagnosed with diverticulitis and colovaginal fistula (
the probable cause of continued urinary infections)
Total hospital stay – 8 days
• admitted on 09/30/2013 and was discharged to home on 10/07/2013
8days
4.
Education: High school education
Occupation: Retired
Marital Status: Divorced with one daughter and brother
Smoker: Tobacco history of 40+ years of 1-2 packs of
cigarettes a day, prior cessation a month ago was reported
5.
Past medical Hx includes:
• Hypercholesterolemia( 10+years)
• Barrett Esophagus ( 10 Years)
• Chronic pain with possible fibromyalgia
• Chronic Bronchitis with Asthma
• Dyslipidemia
• Lumbar Degeneration
• Morbid Obesity
• Chronic Obstructive Pulmonary Disease (COPD)
• Depression
• Chronic Back Pain
Barrett’s Esophagus
6. Surgical History
•Total abdominal Hysterectomy (1995)
•Cholecystectomy (1975)
•Abdominal Hernia Repair (1990)
•Bilateral cataract Surgery (2011 and 2013)
Urinary Tract History
•20+ UTI with most recent MUMH visit ~2 weeks
ago
•Symptoms in past several months include
progressive lower abdominal pain
Some chills
Suprapubic discomfort
8.
MS was admitted with following medications:
• Zantac 300mg, BID
• Pravachol 40mg, daily
• Neurontin 400mg BID
• Escitalopram 20mg,
9.
MS was admitted to MUMH
Weight :127kg, 280lb
Temperature: 36.4C
Blood Pressure: 119/65 mmHg
Pulse: 91 beats/minute
Respiration:18
Alert and orientedx3
Abdomen: obese, mildly tender over suprapubic
area
• Laboratory studies: within normal limits except
Glucose:163
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10. Day
Day 1
Date
09/30/2013
Diagnostic Test
Results
1.Chest, PA and LAT
1.No active
pulmonary disease
2.Esaophagogastroduodenoscopy
plus colonoscopy
2. Acute
diverticulitis
• Medical treatment, Day 1
Zosyn 3.375g IV, every 6 hr for acute diverticulitis
Pt was placed on cardiac monitor, no arrhythmias
Stool culture sent for C.diff
Diet=NPO +ice chips + D5.NS at 100ml/hr
11. Day
Date
Diagnostic Test
Day 2
10/01/2013
Surgical Pathology
1.Duodenum, Biopsy
2. Stomach, Biopsy
3.GEJ, Biopsy
Results
1. Normal findings
2. Mild inflammation,
negative for H-Pylori
3. Epithelial changes
consistent with GERD
4. Colon, Biopsy
(distal Sigmoid)
5. Rectal Biopsy
4. Normal findings
CT Abdomen Pelvis
1. Unchanged appearance of
acute diverticulitis of the
sigmoid colon.
2. Contrast suggests
colovaginal fistula
5. Normal Findings
•Medical Treatment, Day 2
Diet= NPO+ Ice Chips+ D5.NS at 100ml/hr
13. Medical Treatment, Day 3, No acute findings
Gynocologist surgeon, the fistula may close on its own with bowel rest
Diet: NPO, started PSS/PPN
Zosyn continues
IV dilaudid for significant pain
D5.NS at 100ml/hr
Day 4
Diet: NPO +PSS/PPN, No acute findings
Day5
Diet: NPO +PSS/PPN, No acute findings
Day6
Diet: Breakfast: Full Liquid, Lunch: GI Soft, Dinner: Regular
No acute findings, Fistula presumed to have healed
Day7
Diet: Regular, Pt was discharged
14.
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Diet History
Eating a regular diet with no restrictions
Eating less lately, having nausea for ~3months
Drinking Vanilla Ensure once a day
Last Po intake= ½ of an apple, 2 days before admission
Cultural Attitudes that may affect intake: Non reported
•
Weight history
12-13lbs weight loss in one month
BMI:44, morbidly Obese
UBW:294lbs
Physical Activity= Sedentary
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17. Initial Nutrition Consult: 10/01/2013
Diagnosis, 10/01/2013
1-Inadequate energy-protein intake related to diet order as
evidenced by pt NPOx2days with h/o limited intake PTA.
2- Involuntary weight loss related to decreased intake as
evidenced by self reported 13lbs weight loss in a month PTA
Diet Recommendation:
Advance pt diet to clear liquid and then to low residue /low
fiber as tolerated.
18. Nutritional Interventions:
• Recommend physician order a general low residue/low fiber
diet.
• Add commercial beverage
• provide diet education for diverticulitis and fistula
Nutritional goals
• Goal1: Pt receive adequate PO/nutrition support within next
1-2 days
• Goal2: Achieve normal GI function
• Goal 3: meet 70% Kcal and nutrient needs by next day
• Goal 4: Pt will be able to describe why a diet is necessary
and list at least two foods to avoid or eat in limited
amounts.
19. Diagnosis, 10/04/2013
Inadequate energy-protein intake related to NPO/CLD x
5days as evidenced by diet order that does not meet
estimated energy needs.
Diet Recommendation:
Advance pt diet to clear liquid and then to low residue /low
fiber as tolerated.
20. Nutritional Interventions:
• Recommend physician order a general low
residue/low fiber diet.
• Add commercial beverage (Ensure x 1/d)
• provide diet education for diverticulitis and fistula
Nutritional goals
• Goal1: Pt receive adequate PO/nutrition support
within next 1-2 days
• Goal 2: meet 70% Kcal and nutrient needs by next day
• Goal 3: Pt will be able to describe why a diet is
necessary and list at least two foods to avoid or eat in
limited amounts.
21.
22.
Diverticulosis:
• A gastrointestinal disease that affects the colon
• Disease of Western Civilization because of its geographic
preponderance
• Rare in rural Africa and Asia, highest prevalence in the USA, Europe
and Australia
• Caused 814,000 hospitalization and 2, 889 deaths(2010)
Diverticular disease:
• Diverticulosis=Presence of pouches(diverticulas) in the colon
• Diverticulitis= when pouches become inflamed or infected (cause of
inflammation is not clear, may be fecal bacteria
23.
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Risk Factors:
Age
Low fiber diet
Obesity
Sedentary life style
Note: MS is positive for all four of them
Symptoms:
• Most common symptom= abdominal pain
• May experience nausea, vomiting, fever, chills, loss of appetite
Diagnosis:
• Most common diagnostic test= CT scan
• Colonoscopy, digital rectal exam, blood test, stool sample
24. Medical Treatment:
• Intravenous antibiotics
• Bowel rest
NPOClear liquid diet for few days adding soft solids
regular diet)
• Colon resection for patients with recurrent, resistant DV
Nutritional Therapy (DV)
• Focused on fiber intake and probiotic and prebiotic
• To reduce the luminal trauma, avoid high-residue foods( such
as nuts, seeds, popcorn)
Norte: Recent literature has indicated that these
recommendations are controversial and that avoidance is not
necessary
25.
Many clients use Complementary and Alternative
Medications(CAM)
Common CAM therapies:
Glutamin, omega-3 fatty acids, prebiotics, herbs,
wild yam, marshmallow, chamomile, licorice
Homeopathy
Acupuncture
26. • Evidence suggesting that high fiber diet can help
prevent diverticular disease is based largely on
observational, epidemiological studies and few
small clinical studies.
• Recent study found high fiber diet may increase the
prevalence of diverticulosis.
• Not enough evidence to support general
recommendation of low fiber diet during
diverticulitis flare-ups
27. • New studies purport that pt may benefit from consumption of
probiotic.
• Based on review of available research it is reasonable to
recommend high-fiber diet until large scale, well conducted
randomized controlled longitudinal studies demonstrate a
clear benefit of failure of this practice
• Dietitians need to teach patients how to increase their fiber
intake
28. References
Diverticular Disease: University of Maryland Medical Center. Source: http://umm.edu/health/medical/altmed/condition/diverticular-disease.
Accessed November 11, 2013.
National Digestive Diseases Information Clearinghouse (NDDIC). Source: http://digestive.niddk.nih.gov/errors/404.aspx. Accessed December
13, 2013.
Painter N, Burkitt D. Diverticular disease of the colon: A deficiency disease of Western civilization. BMJ. 1971; 2:450–454.
Diverticulosis and Diverticulitis: National Institute of Diabetes and Digestive and Kidney Diseases. Source:
http://digestive.niddk.nih.gov/ddiseases/pubs/diverticulosis/. Accessed December 31, 2013.
Stollman N, Raskin JB. Diverticular disease of the colon. Lancet 2004; 363: 631-639.
Brodribb AJ. Treatment of symptomatic diverticular disease with a high-fiber diet. Lancet 1977; 1: 664–66.
Strate L, Yan L, Walid A, Sapna S, Edward L. Giovannucci. Obesity Increases The Risks Of Diverticulitis And Diverticular Bleeding.
Gastroenterology. 2009; 136(1):115-122.
Tursi A. The current and evolving treatment of colonic diverticular disease. Alimentary Pharmacology & Therapeutics. 2009; 30: 532-546.
Rees Carol. Diverticular Disease: Evidence for Dietary Intervention? Nutrition Issues In Gastroenterology. 2007; 47: 41-46.
Schechter S, Mulvey J, Eisenstat TE. Management of uncomplicated acute diverticulitis: results of a survey. Dis Colon Rectum 1999; 42: 470–
475
Dietary Guidelines for Americans 2010: Fiber. Source: http://www.health.gov/dietaryguidelines/dga2010/dietaryguidelines2010.pdf.
Accessed December 6, 2013
Academy of Nutrition and Dietetics, Nutrition Care Manual. Diverticular Conditions.
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=145209&ncm_toc_id=33991&ncm_heading=Nutrition%2
0Care. Accessed January 29, 2014.
-surgical removal of uterus-Surgcal removal of gallbladder-A hernia is the protrusion of an organ through the wall of the cavity that normally contains it from within
#1 Ruling it out as a cause of recurrent UTIsFistulas may develop if an infected diverticulum reaches an adjoining organ and forms a connection between themThis most frequently occurs between the large intestine and the bladder, and it can lead to an infection of the neighboring kidneys. Fistulas can occur less commonly between the large intestine and either the skin or the vagina.
Who they are, Place and time60-100 = normal resting heart rate for adults ranges from 60-100Lab results are listed in Appendix CLow sodium= kidneys are not working properlyLow potasium= it could be side effect of medication, and also because of vomiting, diarrheaHigh Phos= usually caused by kidney problemsPrealbumin= using the trend it could be indicator of poor intakeA/G ratio= albumin to globulin ration it is indicator of liver function since most enzymes are produced in liver
Posterior-Anterior and lateral D5W vs D5NS=isotonic vs hypertonicD5.NS =hypertonic= moves fluid out of the cells and into the circulationZosyn=antibiotic
2.4 L x 50 g dextrose x 3.4kcal/g =408kcal
Means 60 percent of total about of blood in the left ventricle is pushed out with each heart beat
-dilaudidPeripheral parenteral nutrition
IBW= 209% it is>160% IBW 15-20ml/kg
Inadequate fiber intake related to poor food choices as evidenced byInadequate fluid intakeInappropriate intake of types of carbohydratesAs recommended the goal was to slowly begin low-fiber nutrition therapy until inflammation and bleeding are no longer a risk.High fiber diet meaning 6-10 g beyond the standard recommendations of 20-35 g per dayEmphasize the sources of insoluble fiber or fiber supplements if dietary intake is not sufficient.Ensure adequate fluid intake as fiber amount increase
Pt will identify and reduce intake of specific foods that result in pain, diarrhea, constipationThe pt will identify the food choices that are higher in fiberThe pt will identify sources of probiotic
2.4 liters x 50gm dextrose/liter x 3.4 calories/gm dextrose= 408 caloriesOveral 1500 ml of PPN =670 Kcal
Presence of sac like pouches involving the mucosal layer of the colon. Substantial rise in colonic diverticula with in the past few decades. It affects approximately 5% to 10% of the population by age 50.Long-term changes in dietary intake during human evolution may have contributed to the onset of this disease process( the fairly rapid changes that occurred over the last 200 years in industrialized nations have displaced a once high fiber diet with more refined food items that are lower in fiber and these changes may not be compatible with human digestive abilities.50-60%in patients older than age 80 yearsAge related changes in collagen composition or lack of exercise have been suggested as risc factors for the diseaseConstipation caused by low fiber diet may cause people to strain when passing stool during bowel movement, which may increase pressure in the colonThe increased pressure may cause the colon lining to bulge out through weak spots in the colon wall.2
Diverticulosis is generally asymptomatic and usually diagnosed when individuals undergo gastrointestinal tests such as colonoscopy.Some pt may have elevated white blood cell count or gastronintestinal bleedingPain is Severe and comes onsuddenley
Treatment of Divericulosis includes nutrition therapy focused on fiber intake and probiotic and prebiotic supplementation Medical treatment for diverticulitis includes an order for nothing by mouth with complete bowel restAntibiotics to treat infection if presentDietary fiber contributes to both fecal bulk and a decreased stool transit time.
High fiber diet causes more frequent bowel movements and that increases the risk of diver
Probiotic prevent attacks of diverticulitis completely or significantly reduce frequency of attacks an increase of 6-10 g fiber above the recommended amount fo 25-35 g a day is not easy and dietitions need to talk to their pt to advice them ways to increase their fiber intake.
